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This is a response to 2 previous articles in the Journal which confirmed the association between the risk of myocardial infarction and the taking of combined oral contraceptive pills. An alternative method of contraception should be recommended for women over age 34 years if they have predisposing risk factors, such as diabetes, obesity, hypertension, or Type 2 hyperlipidemia. The effect of the combined estrogen-progestogen pill may be synergistic. With other methods of contraception there may be a greater risk of pregnancy. However, after age 34 the fecundity is less. In case of failure, early abortion, if acceptable, should be offered. Sterilization might be best. Vasectomy for the husband offers a good alternative.
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PMID:Letter: Oral contraceptives in women over 34. 115 1

For women beyond the desire for childbearing, the contraceptive options are discussed as appropriate for the age and in light of risks and benefits. Reeducation and careful history taking are important. A pregnancy for a woman 40 years places a woman at greater risk for an elective abortion and greater risk of maternal mortality from abortion; low dose contraceptive use can have beneficial effects for menopausal women. Methods are grouped as contraceptive steroids (combination pills, progestin-only pills, oral preparations, implants, and injections), IUDs, barrier methods (diaphragms, cervical caps, vaginal sponges, spermicides, and contraceptive film), condoms, sterilization, and natural family planning. Empowering women means providing current scientific information and urging women to examine their lives, and to review how and why contraceptive choices were made, and the consequences of the choices. Sexually transmitted disease counseling is appropriate for women in new relationships. A positive attitude toward menopause needs to be conveyed. Combination pills at the lowest dose possible are recommended for women 35 years who are healthy, nonsmoking (or smoking 15 cigarettes/day), blood group O, and able to derive benefits from the pill. Benefits include a 30% reduction in uterine fibroids and protection against endometrial cancer, and decreased risk of ectopic pregnancy, pelvic inflammatory disease (PID), and iron deficiency anemia. Multivitamin use with the pill is recommended due to reduced liver stores of vitamin A. Women 40 years with a parent dying of cardiac disease 50 years or with a history of hypertension, diabetes, or hyperlipidemia are not suitable candidates. 35 mcg preparations are recommended for women 35-45 years, and 20 mcg for women over 45 years. Progestin-only pills are recommended for those with contraindication to estrogen, but have a higher pregnancy rate. IUD use among older women may be difficult due to cervical or pelvic surgery; there is a higher incidence of PID and ectopic pregnancy with IUD use. Barrier methods are more successful for older women due to the changing vaginal anatomy. Vasectomy is the safest sterilization procedure.
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PMID:Contraception for midlife women. 159 31

The present status of oral contraceptive steroids and the IUD, the 2 most effective and increasingly popular contraceptive methods (used by 41.6% of all U.S. married couples practicing contraception in 1970), is presented. Oral steroid contraceptives with varying quantity and activity of estrogen (ethinyl estradiol or mestranol) and progestogen (norethindrone, norethynodrel, ethynodiol diacetate, or norgestrel), are of 3 types: combination, sequential, and minidose progestogen alone. The most effective contraceptive available is the combined oral pill with a pregnancy rate of less than .2 % per 100 women after 1 year. Contraceptive action is exerted primarily through inhibition of ovulation and secondarily by alterations in cervical mucus, endometrial glands, the ovary, and in the oviduct and uterine muscle. In comparison, sequential oral contraceptives are less effective with greater side effects, and should only be used in women with amenorrhea. Effects of oral contraceptives other than contraception include those on the (1) the primary targets of the female reproductive system, (2) on other endocrine oragans and (3) on the remainder of the body. In the first group, changes may include transitory stromal fibrosis in the ovary, enlarged fibromyomata, intermenstrual bleeding or amenorrhea, increased amount of cervical mucus, polypoid hyperplasia of the endocervical glands, breast tenderness, and changes in lactation. Changes in the second category which may occur affect the adrenal glands, hypothalamus, the thyroid (increased thyroid-binding globulin), and pancreas (alterations in glucose metabolism). Effects on the rest of the body may include increase in serum lipids and changed atherogenic index, abnormalities in liver function, thromboembolism (incidence in oral contraceptive users 4.4 times that in non-users), melasma, alterations in the central nervous system with increased incidence of cerebral vascular accidents, hypertension, and increased body weight. Absolute contraindications to oral contraceptive therapy include cancer of the breast and uterus, pregnancy, active liver disease, hyperlipidemia, and history of gestational diabetes, thromboembolic phenomena or coronary artery disease. Relative contraindications include depression, migraine, myomata of the uterus, hypertension, epilipsy, oligomenorrhea and amenorrhea. Reliable epidemiologic data on IUDs from the Cooperative Statistical Program indicated first year pregnancy rate of 2.5%. Problems with the IUD include: 1) pregnancy with device in situ, which is associated with a higher incidence of spontaneous abortion; 2) ectopic pregnancy, which is prevented at a rate of only 90% compared with intrauterine pregnancies prevented in 97-98%; and 3) expulsions (20% of which are unnoticed), the expulsion rate being higher with decreasing age and parity, higher in the first than second year of use, and higher with smaller than larger devices. A major problem is discontinuation for medical reasons (15% rate in the first year), mainly bleeding and pain. Perforation, another serious complication, occurs initially at time of insertion with an incidence of 1 per 2500 insertions for the loop. IUDs were found to produce a sterile inflammatory tissue reaction, which is postulated as the primary causative factor for their contraceptive effect in humans.
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PMID:Current status of contraceptive steroids and the intrauterine device. 459 80

It is stimulating to ascertain the comparative risk to the woman of hormonal contraceptives of the various kinds used today: combination preparations, which rely on blocking the secretion of gonadotropic hormones by the hypothesis; sequential preparations, which rearrange the physiological relationships of the menstrual cycle; gestagen preparations (minipills), which heighten the viscosity of the cervical mucus; longterm injectable preparations, which initially block ovulation and then act on the cervical mucus; postcoital preparations, which act by inducing abortion of the fertilized egg. Of these the most reliable are the fixed combinations, while sequential preparations are somewhat less so. The minipills are the least reliable. Interaction with other medications can reduce the reliability of these preparations; for instance, women on contraceptives have become pregnant after taking antiepileptic medications containing phenobarbitol and hydantoin. As far as risk is concerned, we must distinguish between those that merely harm the woman and those that pose a threat to life. Some of the former are: bleeding between cycles, failure of menses to appear after cessation of contraception, depression, breast-pains, hypertension, thrombophlebitis, and reduced libido. Hormonal contraceptives also have a series of beneficial effects, especially in women who ordinarily have menstrual difficulties. Among the more serious side effects are: risk of teratogenicity, carcinogenicity, liver problems, thromboses, and infarctions. To reduce the risks of these various side effects, the physician should observe carefully the contraindications: these are both absolute (cerebrovascular and retinal problems, thrombo-embolisms, hepatic disease, diabetes, porphyria, and sickle-cell anemia and relative (migraines, cardiac pains, hyperlipemia, epilepsy, and multiple sclerosis).
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PMID:[Safety and risks of hormonal contraceptives]. 712 52

In order to understand the determinants of oral contraceptive (OC) use in Italy, data were analyzed on 1577 women under age 60 (median age 50 years) admitted as controls in a case-control study of breast cancer. Women were included with acute, non-neoplastic, non-gynecologic, non-hormone-related diseases, admitted between 1991 and 1994 to a network of hospitals in 6 Italian centers. A total of 275 (17.4%) women reported ever use of OCs. OC use was strongly related to the level of education: the multivariate odds ratios (OR) of ever use were 2.2 and 3.5, respectively, in women reporting 7-11 and or= 12 years of schooling (p 0.001) compared to women reporting 7 years of schooling. OC use was inversely related to body mass index (BMI): the OR of ever use was 0.8 and 0.7, respectively, in women with BMI 25 - 30 and or= 30 (p = 0.07) compared to leaner women (BMI, Kg/m2, 25). Parous women more frequently tended to be OC users than nulliparous ones, the estimated OR being 2.4 and 2.3, respectively, in women reporting 1 or 2-3 or more births in comparison with nulliparae. Likewise, women with a history of induced abortions were more frequently ever users (OR for or= 1 induced abortions vs. no induced abortion, 1.8, (95% CI 1.2-2.6). However, no relationship emerged between OC use and history of spontaneous abortions. Finally, there was no relation between pill use and history of hypertension, cholelithiasis, thyroid diseases, hyperlipidemia, family history of breast cancer, uterine fibroids and benign breast disease. Women with a history of diabetes were less likely to be OC users (OR 0.6), but the finding was not significant. The results of this analysis are comparable with those of a study conducted in the same population in the early 1980's, and suggest that sociodemographic and reproductive factors, rather than medical history, are major determinants of OC use in this population.
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PMID:Correlates of oral contraceptive use in Italian women, 1991-93. 884 87

Hypothyroidism affects 4% to 10% of women, increasing with age. Symptoms, which are often nonspecific and subtle, can include: lethargy, mild weight gain, edema, cold intolerance, constipation, mental impairment, dry skin, depression, irregular menses, hoarseness, myalgias, hyperlipidemia, and bradycardia. TSH determination is usually warranted when some of these are present. Confirmation of diagnosis is based on laboratory tests, not symptoms. With Hashimoto's thyroiditis, the most common cause, the thyroid is usually firm and irregular to palpation. Screening is recommended by the American Thyroid Association, American Association of Clinical Endocrinologists and ACOG. Studies indicate that even slight hypothyroidism is associated with increased miscarriage, late fetal demise and lower IQ of offspring. Many believe all women intending conception or pregnancy should be screened. Most patients with even slightly elevated TSH should be treated, though controversy remains. Hypothyroidism is usually permanent, and treatment is life-long; postpartum thyroiditis may be transient. Levothyroxine is the standard treatment. Because of variable bioavailability of some levothyroxine preparations, designation of a specific high-quality brand is appropriate; TSH should be monitored to titrate the dose. The third-generation super-sensitive TSH is the most accurate test for both hypo- and hyperthyroidism. Because estrogen increases levels of thyroid binding globulin, women who are on HRT or OCs, or are pregnant, usually have total T4 levels above the reference range.
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PMID:Hypothyroidism and women's health. 1208 Dec 57

A considerable amount of clinical and experimental evidence now exists suggesting the involvement of free radical-mediated oxidative processes in the pathogenesis of diabetic complications. If the diabetic state is associated with a generalized increase in oxidative stress, it might well be reflected in the alterations in embryonic and fetal development during pregnancy. In the present study, incidence of the malformed fetuses, biochemical parameters and antioxidant system activity of streptozotocin (STZ)-induced diabetic pregnant rats was investigated and the results obtained were compared with those of the control group (non-diabetic). Virgin female Wistar rats were injected with 40 mg/kg streptozotocin (STZ) before mating. All the females were killed on Day 21 of pregnancy and the fetuses were analyzed. A maternal blood sample was collected by venous puncture and the maternal liver was removed for biochemical measurement. The diabetic dams presented hyperglycemia, hyperlipemia, hypertriglyceridemia, hypercholesterolemia, hyperuricemia, decreased reduced glutathione (GSH), hepatic glycogen and superoxide dismutase (SOD) determinations. There was an increased incidence of skeletal and visceral malformation in fetuses from diabetic rats. Our findings suggest that oxidative stress occurs in the diabetic pregnant state, which might promote maternal homeostasis alterations. These diabetic complications might be a contributory factor to conceptus damage causing embryonic death (abortion/miscarriage) or the appearance of malformations in the fetuses of diabetic dams. Antioxidant treatment of women with diabetes may be important in future attempts to prevent congenital malformations.
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PMID:Oxidative stress and diabetes in pregnant rats. 1213 85

The choice of currently available oral contraceptives (OCs) includes combined formulations in varying dosages and monophaic, biphasic, or triphasic form, sequential pills, synthetic progestin-only pills in macro or microdose, and injectable synthetic progestins. Before the advent of microdose pills, products were characterized by progestin or estrogen dominance. Rumors that microdose pills do not completely inhibit ovulation have hindered their acceptance in France, but research has shown that they inhibit ovarian secretions as effectively as more strongly dosed products. Their les profound inhibition of the hypothalamo-pituitary axis raises hopes of a lessened incidence of postpill amenorrhea. Progestin-only microdose pills allow considerable ovarian estrogen secretion, creating a veritable iatrogenic luteal insufficiency. Following the suppression of mestranol, the only estrogen used in OCs is ethinyl estradiol (EE). The only 19-norsteroid progestins which are fixed directly to the progesterone receptors are norethindrone and norgestrel; others such as lynestrenol, ethynodiol diacetate and norethindrone acetate are prohormones. Menstrual problems are among the most frequent side effects of minidose combined pills, but their incidence had dimished with the appearance of biphasic pills and the triphasic pills should offer even greater improvements. The frequency of thromboembolic venous accidents is firectly correlated to the estrogen dose of OCs, but arterial accidents and possibly arterial hypertension appear to be linked to the progestin dose. Synthetic progestins appear to diminish the high density lipoprotein (HDL) fraction of cholesterol and disturb glucose tolerance, while synthetic estrogens augment the HDL fraction of cholesterol and the very low density lipoprotein (VLDL) fraction of triglycerides, modify some coagulation factors, and elevate the plasma level of angiotensinogene. Dose levels and chemical structures of the constituents influence the metabolic effects of pill formulations. In current practice, minidose products are preferred because they cause fewer metabolic changes and are less likely to entail vascular risks. Sequential pills are prescribed for 1 cycle following induced abortion but are not used for long periods because they are not 100% effective, they carry a risk of endometrial hyperplasia, and they appear to increase risks of venous thromboembolism. A combination of 50 mcg EE and 2 mg cyproterone acetate may be prescribed for acne, and minidose combination pills may be used in case of fibroma or endometriosis. In case of contraindications to estrogen, a microdose or injectable progestin can be prescribed if their shortcomings are kept in mind. The current popularity of macrodose progestin-only pills in France has more to do with fashion than with science. All hormonal contraception should be avoided for women at risk, including smokers and those with hyperlipidemia or a family history of vascular accidents.
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PMID:[How to choose an oral contraceptive in 1984]. 1226 9

It is sometimes difficult to plan contraception with a woman who has just delivered a baby, because she is sometime not motivated in the week following delivery, feeling unable to contemplate intercourse because of perineal pain and other discomforts. Effective contraception should be used beginning with the 25th postpartum day because of the subsequent strong possibility of ovulation before the return of menstruation. The woman should be provided with as much information on contraception as possible during this period, and possible contraindications to specific methods should be sought, such as thromboembolic accidents, hyperlipidemia, hypertension, diabetes, infection, ectopic pregnancy, abortion, and desire for subsequent pregnancy. No request for contraception should be ignored and the same method should not be imposed on all women. The topic of contraception should not be deferred until the postpartum check-up in the 2nd month, because 50% of women will have had intercourse by the end of the 2nd month, often unprotected. Local methods such as spermicides and condoms are effective when the couple is motivated and they are well accepted. The thromboembolic risk appears minimal when oral contraceptives (OCs) are begun on the 15th postpartum day for non-breastfeeding women. OCs should not be prescribed for women after prolonged bedrest, and women who previously used pills should have lipid and glucose tests before the 2nd month postpartum consultation. The low dose progestin pill should be preferred to the low dose combined pill if a potential thromboembolic risk exists. Infants of breastfeeding women using pills receive 1/500 of the estrogen dose administered to the mother and 1/1000 of the progestin dose. No effects of these doses have been found on the growth or genital development of infants, and modifications of milk composition are not constant. A low dose progestin pill beginning on postpartum day 20 may however be preferred. It is better to await the return of menses before inserting an IUD because of the danger of expulsion prior to that time. Local methods should not be the only ones recommended in the immediate postpartum period because of the possibility of poor acceptance and unwanted pregnancy resulting from incorrect use. Very high dose OCs should not be prescribed. Long acting injectable progestins should be avoided for breastfeeding women except in cases of serious psychic disturbance because the quantity of hormones entering the milk is much greater than with pills.
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PMID:[Do's and don'ts in post-partum contraception]. 1226 12

BACKGROUND: Acute pancreatitis rarely complicates pregnancy. Although most pregnant women with acute pancreatitis have associated gallstones, less common causes such as drugs have been reported. CASE PRESENTATION: We report the case of a 34-year-old woman who underwent medical abortion with mifepristone and gemeprost and received codeine as pain-relief during the induction of abortion. She developed a severe acute necrotizing pancreatitis which required 14 days of intensive care. Other possible etiological factors, i.e. gallstone, alcohol intake and hyperlipidemia, were excluded. CONCLUSIONS: The reported case of acute pancreatitis was most likely drug-induced.
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PMID:Acute pancreatitis following medical abortion: Case report. 1506 85


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